Scenario: A 52-year-old male patient who is a house painter presents to the office reporting chronic fatigue and “mild” chest pain. When he is painting, the chest pain is relieved after taking a break. He reports that the pain usually lasts 5 minutes or less and occasionally spreads to his left arm before subsiding. The patient was last seen 3 years ago by you, and you recommended diet changes to manage mild hyperlipidemia, but the patient has gained 30 pounds since that time. The patient’s medical history includes anxiety, vasectomy, cholecystectomy, and mild hyperlipidemia. The patient does not smoke or use other tobacco or nicotine products. The patient cares for his wife, who has multiple sclerosis and requires 24-hour care. His daughter and grandson also live with the patient. His daughter assists with the care of his wife, and his job is the major source of income for the family. The initial vital signs are: blood pressure 158/78, heart rate 87, respiratory rate 20, and body mass index 32. As part of the diagnostic work-up, an ECG, lipid levels, cardiac enzymes, and C-reactive protein (CRP) are ordered. The patient reports that he does not have time to “be sick” and says that he needs to take care of everything during this visit so he can return to work and care for his wife.
1. What additional information should you obtain about the pain the patient is experiencing?
2. What additional physical assessments need to be completed for this patient?
3. What differential diagnoses should be considered for the patient?
4. Assuming that the in-office EKG did not indicate any abnormalities, how would you proceed to manage the abnormal subjective and objective findings discovered during this visit? Include specific interventions for each diagnosis in your treatment plan. Provide complete prescription details, follow-up instructions, and potential referrals.
5. What patient teaching will be incorporated into the visit to modify the patient’s risk factors?
6. Include the ICD-10 codes you would choose for each problem addressed and the Evaluation and Management/Office visit code expected for this visit. Keep in mind the length of time it has been since this patient has been seen in the clinic.
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